What hope for the National Health Insurance Scheme in 2010


Many have described the National Health Insurance Scheme (http://www.nhis.gov.ng/website is “down”) as the longest it has taken any project to reach matuaration…even in the Nigerian context (find the law establising it from 1999 here). At the same time….some progress has been made with the emergence of large Health Maintenance Organisations as Hygeia and Total Health. among others. This detailed review of the sector by Chukwumah Muanya in the Guardian  provides a good review of the state of play. Its an interesting read on what will be an extremely important issue in 2010.

Credit to The Guardian for an excellent piece…reproduced in full here.

Not yet assurance for your health

By Chukwuma Muanya
THE National Health Insurance Scheme set up by the government to ameliorate the health burdens of Nigerians is everything but national after several years of implementation. It’s chief executive broods over the kinetic forces hindering the quick spread.

A GLOOMIER picture of the global economic meltdown as it affects the health sector is just emerging.

It is so bad that many Nigerians cannot afford going to hospitals. They rather patronise quacks and roadside drug vendors. Even in states where healthcare is free for the elderly, pregnant women and children under-five, many complain not having enough money for transport and other logistics.

To address this, the Federal Government introduced the National Health Insurance Scheme (NHIS). Health insurance is a social security system that guarantees the provision of needed health services to persons on the payment of token contributions at regular intervals.

The NHIS is a body corporate set up under Act 35 of 1999 by the Federal Government to improve the health of all Nigerians at an affordable cost through various prepayment systems.

But 10 years on, only 5.3 million Nigerians (3.73 per cent of the population) are benefiting from the scheme. The beneficiaries are civil servants in Federal employment, and in Bauchi and Cross River states, and 300,000 pregnant women and children under the Maternal and Child Health Project (MCHP).

There are also private health insurance firms offering services to Nigerians in the organised private sector. Unverified reports put beneficiaries under this platform at about seven million.

Under the MCHP, the NHIS with funds from the Millennium Development Goals (MDGs) office plans to put 600,000 pregnant women and children under five in six states on health insurance by the end of this year as well as start in six other states with funds from the Debt Relief Gain (DRG).

The pilot project, which has enlisted over 300,000 vulnerable women and children, is ongoing in Gombe for the North East, Sokoto for North West, Niger (North Central), Oyo (South West), Bayelsa (South South), and Imo (South East).

However, the NHIS plans to make the scheme mandatory and has set December 2015 deadline to get all Nigerians to be enlisted into the scheme.

But why are many Nigerians not benefiting from the NHIS?

The Executive Secretary, NHIS, Dr. Dogo Mohammed, explains: “The first challenge is the Act, which has a lot of inadequacies and until the right amendments are done, we will not be able to have a very strong legal document to operate.”

The NHIS Governing Council is in the process of amending the Act to transform it into an agency with regulatory powers to make the scheme compulsory.

Mohammed said: “The Act establishing the NHIS makes social insurance optional. From experience, quite a number of potential participants are not participating. Because it is not mandatory you find out that despite our advocacy to states and local government areas (LGAs), they are not doing anything about joining the scheme. And the only way we can make it mandatory is to amend the Act.

“Since 2006, attempts have been made to get this Act changed. The name of NHIS will change because we have realized that the Act gave the scheme a very difficult name to operate.

“The Act as it is does not cover private insurance, the vulnerable group (women and children) but only the formal sector, public servants.

“If we want the NHIS to regulate all the various fields either in the social health insurance, or the private or vulnerable groups, it cannot just be a scheme, it has to be an agency that is going to look like an authority that can monitor various schemes in the country that are to be established”.

He said that the NHIS Council will look at the new draft and made input during its meeting holding from November 24 to 25, before a final draft goes to the Minister of Health who will in turn take it to the Federal Executive Council and from there to the National Assembly.

The NHIS boss said the second major challenge towards making the scheme universal is the three tiers of governance in the country.

The three-tier system of government is another problem because what obtains at the federal level is not necessarily accepted in the states. Now, you are talking about the Federal Government as one entity, and the 36 state governments and the Federal Capital Territory (FCT) as another. It is a problem before you get them to listen to you. By extension, when you go, not all states will say their LGAs are coming along. In the states that we have been, it is only the state employees that are on but not the LGAs employees.

“The third problem is the economic status of the country where over 70 per cent live below $1 a day.

“We have found that if we were to offer the scheme 100 per cent free to people, they will not value it. They will say it is second-best, it does not have quality. In fact, they will say ‘it is for the poor, why should I join this.’

“Another problem is the provision and distribution of medical facilities. The way the facilities are distributed is questionable. Over 90 per cent of our disease-burdens are in the rural areas, but less than 10 per cent of the facilities are in the rural areas. So where you have the disease burden, you do not have the facilities. And where you have the facilities and the human resources comes in as another problem. Many of the qualified human resources are not ready to move to the rural areas because of lack of infrastructure such as schools for the children, potable water, electricity and others.

“Another one is lack of public awareness. No matter what you do, there are some people that do not want to know. They are dogmatic, their mindset is that they do not want to know. Being contributory, some will say it is wrong to pay for it. There is this lack of awareness. And to create awareness is a very expensive thing, not in terms of money but even in human time.”

Mohammed said contrary to widely held belief the NHIS has gone a long way in meeting its objectives of bringing down the cost of healthcare in the country.

He said:
“There are 10 objectives of setting up the NHIS – that people should have easy access to quality healthcare. I have already talked about rising cost of medical care in the world and Nigeria is not an island. So the NHIS is supposed to collapse that rising cost so that you maintain it at an acceptable limit. And that is the basis for the payment mechanism where you say you tag a capitation.”

Capitation is a quotation of money which the NHIS sends every month on behalf of any registered person to the Health Care Provider, whether that person visits a facility of choice or not. Though there have been calls from some quarters for an upward review of the capitation to reflect the present economic realities in the country, it has been N550 since 2005 for the primary level of care.

Mohammed added: “Reducing the rising cost to health is another objective, which people do not realise we have been able to achieve. The second one is to get a fair distribution of contributions for health in order to attack this out of pocket thing. And that is why the contribution is a capitation. That is why somebody on Grade Level 1 contributing just N170 will receive the same care with another on consolidated salary scale and contributing over N10,000. That is, when the fellow paying N170 gets sick with malaria, the treatment is the same as he pays according to his ability. So you find out there is fair distribution, the more you get the more you pay.

“Not only that, another objective is to make sure that this social economic grouping does not give a barrier to somebody to access care where he wants. I can give you an example. Before, it was very difficult for an ordinary fellow on Grade Level 2 to go to Abuja clinic. Today, he can say: ‘I want to go to Abuja clinic’, and he will be treated”.

The NHIS Executive Secretary said the scheme has restored confidence in primary and secondary level of care, unlike what was obtainable in the past where 90 per cent of patients visit the tertiary health centres.

Primary health care is obtained at the Primary Health Centres (PHCs), secondary care at General Hospitals and Medical Centres, while tertiary healthcare is offered at Teaching Hospitals and Specialist Medical Centres.

He said: “We are going to make sure that this lack of confidence for primary and secondary level of care is restored. Everybody rushes to the tertiary level. Having to go to a primary provider is bringing back the former referral system. Because this is your gatekeeper you can only choose your primary provider. When you have a complaint, you go to your primary provider of choice. From there, you may go to the next level. It is the primary provider that will refer you and there is a protocol for that. So you can see that you are getting the proportionate number of patients visiting the appropriate levels of care. That is another objective. We are gradually re-installing some sanity in the system.”

Mohammed said although the mandate is clear, “by 2015, we are supposed to cover every Nigerian.” He said the reality is that one tree does not make a forest, and even if all the money that is supposed to give Nigerians cover to put into the scheme, there will still be issues of capacity, willingness to even participate, the health seeking behaviours of Nigerians, the difficult terrains, the problems of infrastructure, the problem of human resources for heath, and so on.
He said the NHIS cannot deliver on many issues as regards health of Nigerians because the system is weak.
“And there are many non-health related issues that are adding more burden. Today, if you take the environment, we should not just be treating malaria, we should be attacking the vector, we should have a clean environment. That is something that is beyond NHIS. If you come to distribution of facilities, there are also problems with standards. So it is something one cannot say, ‘this is where I want to be’. You see there are so many problems.”


Never doubt that a small group of thoughtful committed people can change the world; indeed it is the only thing that ever has…Margaret Mead

Chikwe Ihekweazu is an epidemiologist and consultant public health physician. He is the Editor of Nigeria Health Watch, and the Managing Partner of EpiAfric (www.epiafric.com), which provides expertise in public health research and advisory services, health communication and professional development. He previously held leadership roles at the South African National Institute for Communicable Diseases and the UK's Health Protection Agency. Chikwe has undertaken several short term consultancies for the World Health Organisation, mainly in response to major outbreaks. He is a TED Fellow and co-curator of TEDxEuston.

Discussion4 Comments

  1. As a Quality Assurance staff in the HMO industry these past 5years, I can say I know first-hand how well this Scheme is doing and the myraid of problems facing it.

    However this article is a very precise chronicle of the NHIS so far, as an insider I must buttress the fact that the Scheme is a laudable one and all hands must be on deck to see it sustained and working optimally.

    Many are jaded by past failed schemes like NSITF, NHF etc but the very nature of health needs and spiralling cost of health-care delivery makes it imperative for the NHIS to be supported and processes sped up for the Scheme to truly embrace all Nigerians, especially the Informal sector and other Vulnerable sectors.

  2. The problem with Nigeria is that we like embarking on projects that are known to fail. There is no documented evidence that Social health insurance has worked any where. In the places where it was started like Germany, it took over 100 yrs to achieve universal coverage, how does Nigeria want to achieve it in 20 yrs. Even the initiators are already thinking of jettisoning social health insurance scheme because all the arguments in support have not held as time passed.
    The World Bank, IMF and WHO through their agencies like IFC will also want to suggest something to Africa because they have termed us poor. We need to think inwards and find out how to solve our problems.
    The problems highlighted here as problems of the NHIS are a little compared to all the problems in the literature with social health insurance.
    The formal sector is the easiest to get enrolled and it took 10yrs. How long will it take to convince the villager that the should embrace insurance when our hospitals are death traps, there is corruption even in our churches.
    We better wake up and develop something realistic.
    Social Health Insurance is a dream. It will not work What you are expecting is for a workforce of less than 25% to cater for 75%. How will it happen

  3. Pls give us a forum to talk about corruption in hospitals. The MDs are stealing the hospital and patients to death. Was invited to FMC Jalingo and one year after, the MD is still in charge and has not been charged to court. Despite being arrested several times by EFCC and detained and released.
    These stories are the same for many hospitals. That is why billions have continued to be put into these hospitals with no significant change in the health indices.
    Unless we name and shame rogue doctors incharge of hospitals, we might not make progress. Pls give us the opportunity to fight this war here. Our people are dying and the moral of the work force is low because of wide spread corruption.

  4. I agree with the first “Anonymous” commentator that “We need to think inwards and find out how to solve our problems”; however that thinking does not take place in its best form by standing back and avoiding to get your hands dirty. You must start andn then your creative juices will begin to flow.

    Nigeria is benefiting even while NHIS is still at a sub-opptimal stage. We are seeing live feedback! We are EXPERIENCING change. I agree it is gradual and each country needs to work out an acceptable and realistic timeline for itself, for this and other developmental initiatives.

    We can then creatively modify, rather than reinvent the wheel.

    I for one am ready to work with the IFC and NHIS project. It must be done.

    The health sector collaboration, consolidation and cohesiveness is a necessity to get any health insurance scheme working and its not by mouth, its by creatively putting in place a system for integration, communcation, data gathering, monitoring and evalution (all in situ).

    Then can we begin to build confidence within the system that programmes will work.

    Then, we can go to town to develop creative programmes. Systemm first. Effective communication and acceptability by the target will take place! It is a given.

    I rest my case for now.

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